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HomeMy WebLinkAboutPR 22529: CONTRACT WITH THE DEPARTMENT OF STATE HEALTH SERVICES IMMUNIZATION BRANCH. NO MATCH REQUIRED E.A City of NMI o rt rth u �� Date: April 25, 2022 To: Ron Burton, City Manager From: Judith A. Smith, RN, BSN, Director of Health Services RE: Contract Amendment between the City of Port Arthur and the Department of State Health Services Immunization Branch. No match required Nature of the Request: This contract amendment will allow the Health Department to continue its immunization program for children, adolescents and adults to eliminate barriers, expand immunization delivery, and establish uniform policies. The contract period is from September 1, 2022 to August 31, 2023. The contract budget is amended to add funding for state fiscal year 2023 in the amount of $162,630.00. The total amount of the grant award will not exceed $875,366.00. There is no cash match for this grant. Staff Analysis, Considerations: These grant funds cover salaries and fringe for 3 full-time employees, one licensed nurse, one Administrative staff and one Community Outreach staff. Recommendations: It is recommended that the City Council approve P.R. No. 22529, amending the contract between the City of Port Arthur and the Department of State Health Services/Immunization Division. This grant will allow the Health Department to continue the immunization program for children, adolescents, and adults. Budget Considerations: This grant will cover personnel salaries and fringe benefits. The additional funds will help fund staff for the COVID vaccination Hub. "REMEMBER WE ARE HERE TO SERVE THE CITIZENS OF PORT ARTHUR" P.O.BOX 1089•PORT ARTHUR,TX 77641-1089.409/983-8101•FAX 409/982-6743 P. R. No. 22529 04/25/2022-js RESOLUTION NO. A RESOLUTION APPROVING THE FY 2022-2023 CONTRACT AMENDMENT BETWEEN THE CITY OF PORT ARTHUR AND THE DEPARTMENT OF STATE HEALTH SERVICES, IMMUNIZATION BRANCH-LOCAL TO EXTEND THE CONTRACT PERIOD THROUGH AUGUST 31, 2023 AND ADD FUNDING IN THE AMOUNT OF $162,300.00. THE TOTAL AMOUNT OF THIS CONTRACT WILL NOT EXCEED $875,366.00. NO CASH MATCH IS REQUIRED. WHEREAS, the contract between the City of Port Arthur and the Department of State Health Services provides financial assistance to the Port Arthur City Health Department to supplement the delivery of public health services. This contract amendment will allow the City's Health Department to continue the immunization program for children, adolescents, and adults and will help to eliminate barriers, expand immunization delivery, and establish uniform policies; and, WHEREAS, pursuant to Resolution No.21-123, council approved the FY 2021-2022 contract on March 30, 2022, and now The Department of State Health Services desires to amend the contract to add $162,630.00 to cover the contract period September 1, 2022 through August 31, 2023. The total grant award will not exceed $875,366.00. NOW THEREFORE BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT ARTHUR: Section 1. That, the facts and opinions in the preamble are true and correct. Section 2. That, the City Council of the City of Port Arthur hereby approves the contract amendment between the City of Port Arthur and the Department of State Health Services. P. R. No. 22529 04/25/2022-js Section 3. That, the City Council deems it is in the best interest of the City to approve and authorize the City Manager and the Director of the City's Health Department to execute the contract amendment between the Department of State Health Services and the City of Port Arthur, Texas, to continue the immunization program as delineated in Exhibit"A". Section 4. That, a copy of the caption of this Resolution be spread upon the Minutes of the City Council. READ, ADOPTED, AND APPROVED, this day of May, 2022 A.D., at a Regular Meeting of the City Council of the City of Port Arthur, Texas by the following Vote: AYES: Mayor: , Councilmembers: NOES: Mayor ATTEST: Sherri Bellard, City Secretary 1AP OVED AS TO FORM: (iiit-e (tom f�7 Val Tizeno, ity Attorney t� P. R. No. 22529 04/25/2022-js APPROVED FOR ADMINISTRATION: 9.Ud v /in lib Ron Burton, City Manager Judith Smith, RN, BSN, Director of Health EXHIBIT "A" DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 DEPARTMENT OF STATE HEALTH SERVICES CONTRACT No.HHS000109900001 AMENDMENT No. 4 The DEPARTMENT OF STATE HEALTH SERVICES (DSHS or System Agency) and CITY OF PORT ARTHUR (Grantee), Parties to that certain Immunization/Locals Grant Program Contract, effective September 1, 2018, and denominated DSHS Contract No. HHS000109900001 (the Contract), as amended, now want to further amend the Contract. WHEREAS, DSHS wants to exercise its option to extend the Contract term for an additional year, representing the fourth and final extension option("Fourth and Final Extension Option"); WHEREAS, DSHS wants to add funds to the Contract to pay for services provided during the extended term; WHEREAS, DSHS wants to revise ATTACHMENT A, STATEMENT OF WORK and ATTACHMENT H-2,IMMUNIZATION/LOCALS PROGRAM GUIDANCE DOCUMENT. Now,THEREFORE, the Parties agree as follows: 1. The Contract is extended in accordance with SECTION III,DURATION, for an additional year. The Fourth and Final Extension Option shall begin September 1, 2022 and end August 31, 2023, unless terminated sooner. 2. SECTION IV, BUDGET, of the Contract, is amended to increase funding in the amount of $162,630.00 for State Fiscal Year 2023 ("FY 2023"). The total not-to-exceed amount of this Contract is increased to $875,366.00. All expenditures of the additional funds must conform with ATTACHMENT B-4,FY 2023 BUDGET. 3. ATTACHMENT A-1, REVISED STATEMENT OF WORK, of the Contract, is deleted and replaced in its entirety with ATTACHMENT A-2,FY 2023 STATEMENT OF WORK. 4. ATTACHMENT B-3, REVISED BUDGET, of the Contract, is supplemented with the addition of ATTACHMENT B-4,FY 2023 BUDGET. 5. ATTACHMENT H-2, IMMUNIZATION/LOCALS PROGRAM GUIDANCE DOCUMENT is deleted and replaced in its entirety with ATTACHMENT H-3, IMMUNIZATION/LOCALS PROGRAM GUIDANCE DOCUMENT. 6. This Amendment shall be effective September 1, 2022. 7. Except as modified by this Amendment, all terms and conditions of the Contract, as amended, shall remain in full force and effect. DSHS Contract No.HHS000109900001 Page 1 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 8. Any further revisions to the Contract shall be by written agreement of the Parties. SIGNATURE PAGE FOLLOWS DSHS Contract No.HHS000109900001 Page 2 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 SIGNATURE PAGE FOR AMENDMENT No. 4 DSHS CONTRACT No. HHS000109900001 DEPARTMENT OF STATE HEALTH CITY OF PORT ARTHUR SERVICES By: By: Date of Signature: Date of Signature THE FOLLOWING DOCUMENTS ARE ATTACHED TO THIS AMENDMENT AND THEIR TERMS ARE INCORPORATED INTO THE CONTRACT BY REFERENCE: ATTACHMENT A-2—FY 2023 STATEMENT OF WORK ATTACHMENT B-4 -FY 2023 BUDGET ATTACHMENT F-4 -FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT(FFATA) ATTACHMENT H-3- IMMUNIZATION/LOCALS PROGRAM GUIDANCE DOCUMENT ATTACHMENTS FOLLOW DSHS Contract No.HHS000109900001 Page 3 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 ATTACHMENT A-2 FY 2023 STATEMENT OF WORK I.GRANTEE RESPONSIBILITIES Grantee will: A. Implement and operate an immunization program for children, adolescents, and adults, with special emphasis on accelerating interventions to improve the immunization coverage of children three (3) years of age or younger (birth to 35 months of age). Grantee shall incorporate traditional and non-traditional systematic approaches designed to eliminate barriers, expand immunization capacity, and establish uniform operating policies, as described herein. B. Be enrolled as a provider in the Texas Vaccines for Children (TVFC) and the Adult Safety Net (ASN) Programs by the effective date of this Contract. This includes a signed Deputization Addendum Form (EF11-13999). C. Comply with written policies and procedures provided by DSHS in managing vaccines supplied through the ASN and TVFC Programs, including guidelines for proper storage, handling, and safeguarding of vaccines in the event of natural disaster. D. Adhere to DSHS Immunization updated guidance according to Attachment H-3, Immunization/Locals Program Guidance Document. E. Maintain staffing levels to meet required activities of the Contract and ensure staff funded by this Contract attend required training. F. Report all notifiable conditions as specified in Texas Administrative Code(TAC)Title 25, Part I §§ 97.1-97.6, as amended, and as otherwise required by law. G. Report all vaccine adverse event occurrences in accordance with the 1986 National Childhood Vaccine Injury Act (NCVIA) 42 U.S.C. § 300aa-25 (located at http://vaers.hhs.gov/ or 1-800-822-7967), as amended. H. Sustain a network of TVFC/ASN providers to administer vaccines to program-eligible populations by conducting the following activities: 1. Ensuring New Provider Checklist is completed; 2. Conducting quality assurance reviews; 3. Ensuring annual influenza pre-book survey is completed; 4. Conducting compliance site-visits; 5. Conducting unannounced storage and handling visits; and 6. Ensuring providers adhere to the vaccine borrowing procedure. I. Participate in audits and assessments through the following activities: DSHS Contract No.HHS000109900001 Page 4 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 1. Completing and submitting through Child Health Reporting System(CHRS)all audits and assessments conducted on childcare facilities and Head Start Centers; 2. Completing audits, assessments and retrospective surveys of public and private schools; 3. Reviewing monthly reports to ensure data quality; 4. Reviewing the monthly Provider Activity Reports; 5. Reviewing the quarterly Consent Accepted Rate Evaluations; and 6. Conducting quality improvement assessments of Texas Immunization Registry organizations. J. Provide education and outreach activities regarding vaccines and vaccine-preventable diseases, Texas Immunization Registry, and TVFC and ASN Programs to the following: 1. American Indian Tribes; 2. Schools and childcare facilities; 3. Healthcare workers; and 4. Community and general public. K. Not deny vaccinations to recipients because they do not reside within Grantee's jurisdiction or because of an inability to pay an administration fee. L. Be responsible for identification and case management of all hepatitis B surface antigen (HBsAg)-positive pregnant women. Grantee shall ensure timely newborn post- exposure prophylaxis (PEP) with hepatitis B vaccine and hepatitis B immune globulin (HBIG), timely completion of doses two and three of hepatitis B vaccine, and timely completion of post-vaccination serologic testing(PVST). M. Be responsible for assessing and/or auditing coverage rates and/or compliance with vaccine requirements at assigned schools and childcare facilities in accordance with the Population Assessment Manual, which is distributed annually from DSHS. N. Transfer(which may include shipping)overstocked vaccines and vaccines approaching expiration to alternate providers for immediate use when instructed to do so by the DSHS Public Health Region(PHR) Immunization Program Manager to avoid vaccine waste. Grantee is responsible for covering the cost to ship overstocked vaccines and vaccines approaching expiration. O. Receive written approval from DSHS before varying from applicable policies, procedures, protocols, and/or work plans, and must update and disseminate its implementation documentation to its staff involved in activities under this Contract within forty-eight (48)hours of making approved changes. P. Review monthly Contract funding expenditures and salary savings from any Contract- paid staff vacancies and revise spending plan to ensure that all funds will be properly expended under this Contract before the end of the Contract term. DSHS Contract No.HHS000109900001 Page 5 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 Q. Submit out-of-state travel requests to the Immunization Section for approval when utilizing Contract funds or program income. R. Report the number of doses administered to underinsured children monthly,as directed by DSHS. S. Report the number of unduplicated underinsured clients served, as directed by DSHS. T. Complete and submit Immunization Inter-Local Agreement (ILA) Quarterly Report form, utilizing the format provided by the DSHS Immunization Section and available at https://dshs.texas.gov/immunize/lhd.shtm,by the report due date. If the due date falls on a weekend or state approved holiday, the report is due the next business day. Report Type Reporting Period Report Due Date Programmatic 09/1/2022 to 11/30/2022 12/31/2022 Programmatic 12/1/2022 to 02/28/2023 03/3 1/2023 Programmatic 03/1/2023 to 05/30/2023 06/30/2023 Programmatic 06/1/2023 to 08/31/2023 09/30/2023 Submit quarterly reports electronically through an online tool according to the timeframes stated above. DSHS Immunization Section will provide instructions at the beginning of each state fiscal year through CMS. Supplemental report documents (PEAR and AFIX reports, vacancy letters, etc.) should be sent to dshsimmunizationcontracts(c,dshs.texas.gov. II. PERFORMANCE MEASURES A. The System Agency will monitor the Grantee's performance of the requirements in this Attachment A-2 and compliance with the Contract's terms and conditions. III. INVOICE AND PAYMENT A. Grantee shall request monthly payments using the State of Texas Purchase Voucher (Form B-13) at http://www.dshs.texas.gov/grants/forms.shtm and submitting acceptable supporting documentation for reimbursement of the required services/deliverables. Vouchers and supporting documentation shall be submitted to System Agency no later than thirty (30) days after the last day of each month. Documentation shall be submitted in a format approved by DSHS Immunization Section. At a minimum vouchers should include: 1. Grantee name, address, email address,vendor identification number,and telephone number; DSHS Contract No.HHS000109900001 Page 6 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 2. DSHS Contract or Purchase Order number; 3. Dates services were completed and/or products were delivered; 4. The total invoice amount; and 5. DSHS Supporting documentation. B. Voucher and supporting documentation shall be mailed or submitted by fax or electronic mail to DSHS Claims Processing Unit at the address/number below, and to the Immunization Section at DSHSImmunizationContracts@dshs.texas.gov. Department of State Health Services Claims Processing Unit, MC 1940 1100 West 49th Street P.O. Box 149347 Austin, TX 78714-9347 FAX: (512)458-7442 EMAIL: invoices a,dshs.texas.gov and to CMSinvoices@dshs.texas.gov Grantee will be paid on a cost reimbursement basis and in accordance with the Budget in Attachment B-4, FY 2023 Budget of this Contract. DSHS Contract No.HHS000109900001 Page 7 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 ATTACHMENT B-4 FY 2023 BUDGET Organization Name: City of Port Arthur Program ID: IMM/LOCALS Contract Number: HHS000109900001 Budget for FY 2023 Budget Categories September 1, 2022 - August 31, 2023 Personnel $127,763.00 Fringe $34,867.00 Travel $0.00 Equipment $0.00 Supplies $0.00 Contractual $0.00 Other $0.00 Total Direct $162,630.00 Indirect $0.00 Total $162,630.00 Remainder of page intentionally left blank DSHS Contract No.HHS000109900001 Page 8 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-46F8-9618-4AC2AA9A5FD1 ATTACHMENT F-4 Fiscal Federal Funding Accountability and Transparency Act (FFATA)CERTIFICATION The certifications enumerated below represent material facts upon which DSHS relies when reporting information to the federal government required under federal law. If the Department later determines that the Contractor knowingly rendered an erroneous certification, DSHS may pursue all available remedies in accordance with Texas and U.S. law. Signor further agrees that it will provide immediate written notice to DSHS if at any time Signor learns that any of the certifications provided for below were erroneous when submitted or have since become erroneous by reason of changed circumstances. If the Signor cannot certify all of the statements contained in this section, Signor must provide written notice to DSHS detailing which of the below statements it cannot certify and why. Legal Name of Contractor: FFATA Contact#1 Name,Email and Phone Number: City of Port Arthur Judith A.Smith,RN BSN judith.smith@portarthurtx.gov (409)983-8832 Primary Address of Contractor: FFATA Contact#2 Name,Email and Phone Number: 449 Austin Avenue Kandy Daniel Port Arthur,TX,77640 kandy.daniel@portarthurtx.gov (409)983-8174 ZIP Code:9-digits Required www.usps.com DUNS Number:9-digits Required www.sam.gov 776110 5,802 13713109 State of Texas Comptroller Vendor Identification Number(VIN)14 Digits 174,001885p011 Printed Name of Authorized Representative Signature of Authorized Representative Judith A. Smith p—Docusigned by: itAli w StMI Title of Authorized Representative be{€B48504AED30471... Director of Health April 22,2022 -1- Department of State Health Services Form 4734—June 2013 DSHS Contract No.HHS000109900001 Page 9 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 Fiscal Federal Funding Accountability and Transparency Act (FFATA)CERTIFICATION As the duly authorized representative(Signor)of the Contractor,I hereby certify that the statements made by me in this certification form are true,complete and correct to the best of my knowledge. Did your organization have a gross income, from all sources, of less than $300,000 in your previous tax year?❑Yes b7 No If your answer is"Yes",skip questions"A","B",and"C"and finish the certification. If your answer is"No",answer questions"A"and"B". A.Certification Regarding%of Annual Gross from Federal Awards. Did your organization receive 80% or more of its annual gross revenue from federal awards during the preceding fiscal year?❑Yes No B.Certification Regarding Amount of Annual Gross from Federal Awards. Did your organization receive$25 million or more in annual gross revenues from federal awards in the preceding fiscal year?❑Yes ail No If your answer is"Yes"to both question"A"and"B",you must answer question"C". If your answer is "No" to either question "A" or "B", skip question "C" and finish the certification. C.Certification Regarding Public Access to Compensation Information. Does the public have access to information about the compensation of the senior executives in your business or organization (including parent organization, all branches, and all affiliates worldwide)through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934(15 U.S.C. 78m(a), 78o(d))or section 6104 of the Internal Revenue Code of 1986?[]Yes ❑ No If your answer is"Yes"to this question,where can this information be accessed? Information can be accessed through the City Secretary's office If your answer is "No" to this question, you must provide the names and total compensation of the top five highly compensated officers below. Provide compensation information here: N/A -2- Department of State Health Services Form 4734—June 2013 DSHS Contract No.HHS000109900001 Page 10 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 ATTACHMENT H-3 IMMUNIZATION/LOCALS PROGRAM GUIDANCE DOCUMENT GRANTEE RESPONSIBILITIES 1. PROGRAM& CONTRACT MANAGEMENT 1.1. PROGRAM MANAGEMENT 1.1.01 Implement and operate an Immunization Program as a Standard Responsible Entity (Universal) 1.1.02 Identify at least one individual to act as the program contact in Required the following areas: Activity 1. Immunization Program Manager; 2. RE Contract Coordinators; 3. RE School Compliance Coordinators; 4. RE Perinatal Hepatitis B Case Manager; 5. RE Disease Surveillance Coordinators; 6. RE Clinical Coordinators; 7. RE Texas Immunization Registry Coordinators; 8. RE TVFC & ASN Coordinators; and 9. RE Coalition Coordinators 1.1.03 Attend all required trainings for each Area of Work as specified Required in the Immunization Program Contractor's Guide. Ensure that Activity the Immunization Program Manager and TVFC and ASN Coordinator attend the annual Immunization Unit mandatory in- person meeting 1.1.04 Comply with the DSHS Immunization Contractor's Guide for Standard Local Health Depat tinents which includes all immunization (Universal) grant objectives and required activities. The Immunization Contractor's Guide is Attachment A of the ILA and will be attached to the executed contract 1.1.05 Annually complete one LHD Deputization Addendum Form Required (EF11-13999) for all Provider Identification Numbers (PIN) Activity associated with the LHD Grantee to ensure eligibility to provide immunization services to underinsured children 1.1.06 Maintain staffing levels adequate to meet the required activities Standard of this contract and to assure expenditure of all contract funds (Universal) DSHS Contract No.HHS000109900001 Page 11 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 1.1.07 Develop and implement an employee immunization policy for Required Grantee's immunization program staff according to CDC Activity recommendations 1.1.08 Maintain a record of orientation (new staff) and ongoing Required training for existing contract-funded staff involved in the Activity provision of immunization services 1.1.09 Inform DSHS (in writing) of any changes (both departures and Required arrivals) in LHD Medical Director, Immunization Program Activity Manager and all other positions listed under activity 1.1.02 within 30 days of staffing changes 1.1.10 Submit a written notification for contract-funded staff positions Required that remain vacant more than 90 days Activity 1.1.11 Have a standard method to document all work time spent Standard performing immunization activities for staff who are partially (Universal) funded with immunization contract funds 1.1.12 Use the results of the community assessment conducted in Suggested activity 4.7.01 to review and address an immunization need Activity within the LHD jurisdiction 1.2. PROGRAM COMPLIANCE 1.2.01 Comply with all applicable federal and state regulations and Standard statutes as amended, including, but not limited to: (Universal) 1. Texas Human Resources Code §42.043; 2. Texas Education Code §§38.001-38.002; 3. Texas Health and Safety Code §§12.032-12.033, 81.023, and 161.001-161.009; 4. Texas Administrative Code (TAC) Title 25, Chapter 97; 5. TAC Title 25, Chapter 96; 6. TAC Title 25, Chapter 100; 7. 42 USC §§247b and 300aa-25; 8. Omnibus Budget Reconciliation Act of 1993; and 9. 26 USC §4980B 1.2.02 Ensure compliance with Health and Human Services (HHS) Standard Deputization Guidance. Activities under this requirement (Universal) shall be conducted in accordance with the DSHS Immunization Contractor's Guide for Local Health Depai tments 1.3. FINANCIAL MANAGEMENT DSHS Contract No.HHS000109900001 Page 12 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 1.3.01 Agree DSHS reserves the right, where allowed by legal Standard authority,to redirect funds in the event of financial shortfalls (Universal) 1.3.02 Submit monthly invoices with appropriate supplemental Required documentation and request monthly payments using the State Activity of Texas Purchase Voucher(Form B-13) and in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments 1.3.03 Agree DSHS will pay Grantee on a cost reimbursement basis Standard (Universal) 1.3.04 Adhere to travel rates set by the State of Texas TexTravel Standard unless the LHD has their own travel poli y. (Universal) 1.3.05 Review monthly contract funding expenditures to ensure that all Standard funds will be properly expended before the end of the contract (Universal) period 1.3.06 Lapse no more than 5 percent of total funded amount of the Required contract Activity 1.3.07 Submit requests to move more than 25% of the total contract Standard amount between direct budget categories in writing to the (When DSHS Contract Management Section(CMS) in Austin and Applicable) obtain approval before monies can be transferred 1.3.08 Expend funds consistently throughout the contract term, Suggested approximately 25%per quarter Activity 1.4. CONTRACT MANAGEMENT 1.4.01 Initiate the purchase of approved equipment purchases in the first Standard quarter of the Contract term. Requests to purchase previously (When approved equipment after the first quarter must be submitted to the Applicable) contract manager. Changes to the approved equipment budget category must be approved by DSHS prior to the purchase of equipment. If a Grantee would like to deviate from the approved equipment budget, a written request to amend the budget is required 1.5. CONTRACT QUALITY ASSURANCE 1.5.01 Participate in remote and on-site technical assistance Required Activity 1.5.02 Participate in on-site contract evaluation visits Required Activity DSHS Contract No.HHS000109900001 Page 13 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 1.6. CONTRACT ACCOUNTABILITY 1.6.01 Submit Corrective Action Plan(CAP) letter to Public Health Region Required Program Manager and DSHS Contract Management Section(CMS) Activity within 30 days after the date of the written notification from DSHS CMS of the on-site evaluation findings (if applicable) 1.6.02 Maintain property records for property and equipment funded or Standard property provided by grant funds (Universal) 1.7. REQUIRED REPORTING 1.7.01 Complete and submit Immunization Inter-Local Agreement(ILA) Required Quarterly Report and supplemental documents according to the Activity formats, mechanisms, and timeframes specified in the DSHS Immunization Contractor's Guide for Local Health Departments 1.7.02 Report program income (PI) generated as a result of the DSHS Required immunization contract activities on the quarterly financial status Activity report(FSR) 1.7.03 Ensure all program income (PI) generated as a result of the DSHS Standard immunization contract activities is expended in accordance with the (Universal) DSHS Immunization Contractor's Guide for Local Health Departments 1.7.04 Submit quarterly FSRs to Accounts Payable by the last business Required day of the month following the end of each quarter for review and Activity financial assessment. Submit the final FSR no later than forty-five (45) calendar days following the end of the applicable term 2. FACILITY IMMUNIZATION ASSESSMENTS 2.1. CHILDCARE& SCHOOL COMPLIANCE 2.1.01 Assess compliance with vaccine requirements at assigned Standard schools and childcare facilities (Universal) 2.1.02 Complete 100%of assigned childcare facility Required audits/assessments. By July 15 of contract year, local health Activity department staff will complete 100%of assigned childcare audits and submit into the Child Health Reporting System (CHRS) DSHS Contract No.HHS000109900001 Page 14 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 2.1.03 Complete 100%of assigned public and private school audits, Required assessments, and/or validation/retrospective surveys in Activity accordance with the DSHS Immunization Contractor's Guide for Local Health Departments by June 15 of contract year, local health department staff will complete 100% of assigned school audits and submit electronically(Alchemer,possibly via email) 2.2. CHILDCARE& SCHOOL COMPLIANCE QA 2.2.01 Provide education to school and childcare facilities with high Required provisional, delinquency, and/or exemption rates at time of Activity audit or when noncompliant records are identified. Report education provided to school or childcare staff in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments 2.2.02 Provide feedback to DSHS ACE Group regarding Required trends/issues for vaccine requirements in accordance with the Activity DSHS Immunization Contractor's Guide for Local Health Departments 2.2.03 Contact schools/districts to remind them to report during the Required Annual School Survey reporting period in accordance with Activity the DSHS Immunization Contractor's Guide for Local Health Departments 2.3. FIRST RESPONDER IMMUNIZATION ASSESSMENTS 2.3.01 Educate and inform first responder facilities on the use of the Suggested Texas Immunization Registry to assess first responder Activity immunization records and forecast any future immunization needs. Use the First Responder Immunization Toolkit(FRIT) to drive these activities 3. MANAGING TVFC AND ASN PROVIDERS 3.1. PROVIDER RECRUITMENT 3.1.01 Recruit additional TVFC providers to administer vaccines to Suggested program-eligible populations. The goal is to increase each Activity local health department's provider enrollment by 5% DSHS Contract No.HHS000109900001 Page 15 of 33 Amendment 4 DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 3.1.02 Ensure New Enrollment Checklist(11-15016)is completed Required for all clinics that join the TVFC/ASN Program Activity 3.1.03 Collaborate with medical societies and/or local health Suggested provider organizations to identify providers to recruit and Activity enroll 3.2. PROVIDER RETENTION 3.2.01 Sustain a network(through re-enrollment)of TVFC providers Required Activity to administer vaccines to program-eligible populations 3.2.02 Promote TVFC and ASN Provider achievements: Suggested Activity - Implement incentives for provider sites that reach vaccination coverage rate goals; and - Implement incentives to recognize sites during national observances(i.e.NIIW,NIAM,and NNW) 3.3. PROVIDER EDUCATION 3.3.01 Provide a training for TVFC and ASN providers within the Suggested LHD Grantee's jurisdiction on the policies outlined in the Activity TVFC and ASN Provider Manual and recommended procedures for implementing them. These include: - procedures for following storage and handling guidelines; - procedures for vaccine management; - procedures for using the DSHS vaccine management system(VAOS); - procedures for vaccine borrowing; - procedures for other compliance guidelines; - appropriate reporting of vaccine adverse events; - appropriate routine and emergency vaccine storage and handling plans;and - meeting the federal requirement that the most current Vaccine Information Statements (VIS) available at https://www.cdc.gov/vaccines/hcp/vis/index.html distributed to patients prior to patient vaccination DSHS Contract No.H S000109900001 Page 16 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 3.3.02 Notify providers of TVFC and ASN updates and changes to Standard program policies and procedures. (Universal) Notify TVFC/ASN providers of the following: - CDC and DSHS Announcements; - TVFC/ASN Trainings; - Vaccine storage and handling policy updates; - Vaccine ordering changes; and - Vaccine choice 3.3.03 Educate and assist TVFC and ASN providers on a quarterly Standard basis with Provider Choice, as necessary (Universal) 3.3.04 Inform TVFC and ASN providers of the most up-to-date, Standard DSHS-produced immunization information for their offices (Universal) 3.3.05 Identify TVFC and ASN providers experiencing high volumes Required Activity of vaccine loss and develop process improvements/trainings aimed at reducing the amount of vaccine loss (including wasted and expired) in their clinics 3.4. PROVIDER VACCINE MANAGEMENT 3.4.01 Utilize the DSHS Vaccine Allocation and Ordering System Required Activity (VAOS) reports and other provider submitted reports to perform 100% of quality assurance reviews on the following TVFC and ASN: - monthly biological reports (doses administered and current inventory); -vaccine orders; -temperature log; and - clinic hours of operation from TVFC and ASN providers in LHD Grantee's jurisdiction. Address all issues identified during review 3.4.02 Transfer vaccines that cannot be stored within provider Standard offices (ex. accidental large orders) and vaccines (Universal) approaching expiration between providers in LHD Grantee's jurisdiction for immediate use DSHS Contract No.HHS000109900001 Page 17 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 3.4.03 Ensure provider participation in vaccine ordering and Standard inventory management using the Vaccine Allocation and (Universal) Ordering System(VAOS): - Educate providers regarding vaccine ordering policies; and -Train providers to use VAOS for inventory and order entry 3.4.04 Assist TVFC and ASN providers in LHD Grantee's Standard jurisdiction on the maintenance of appropriate vaccine stock (Universal) levels. Activities under this requirement shall be conducted in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments and the current TVFC and ASN Program Operations Manual for Responsible Entities 3.4.05 Train TVFC and ASN providers within LHD Grantee's Standard jurisdiction to ensure that expired and spoiled/wasted (Universal) vaccines are appropriately identified and entered into the Vaccine Allocation and Ordering System (VAOS). Train providers to complete returns to CDC's centralized distributor within six months of product expiration 3.4.06 Ensure that 100% of TVFC providers within the LHD Required Activity Grantee's jurisdiction complete the annual influenza pre-book survey 3.5. PROVIDER QUALITY ASSURANCE 3.5.01 Utilize the CDC Provider Education Assessment and Reporting Required Activity (PEAR) system and CDC Immunization Quality Improvement for Providers (IQIP) database to document TVFC compliance and IQIP site visits for all subcontracted clinics and non-LHD Grantee's clinics (as applicable) 3.5.02 Utilize the CDC PEAR system and directly enter data into PEAR Required Activity to document TVFC unannounced storage and handling visits to a minimum of 10% of providers within the LHD Grantee's jurisdiction 3.5.03 Utilize the CDC PEAR system and directly enter data into PEAR Required Activity to document TVFC Unannounced Storage and Handling Visits, Compliance Visits and other visits conducted at TVFC provider offices 3.5.04 Complete and document 100% of the follow-up activities for Required Activity TVFC quality assurance visits within required timeframes DSHS Contract No.HHS000109900001 Page 18 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 3.5.05 Utilize Texas Immunization Registry or DSHS-provided coverage Required Activity rates to assess immunization practices and coverage rates for all subcontracted entities and non-LHD Grantee's clinics (as applicable) 3.5.06 Review 100%of re-enrollment applications from TVFC and ASN Required Activity providers in your jurisdiction by the DSHS specified deadline 3.5.07 Ensure that expired, wasted, and unaccounted-for vaccines Standard (excluding flu) do not exceed 5% in TVFC provider clinics within (Universal) the LHD Grantee's jurisdiction 3.5.08 Review monthly reports to ensure data quality. This includes: Required Activity - Identify sites that have not administered or ordered vaccine in the previous six months. Conduct a discussion and develop a plan of action; - Identify sites that are suspended to ensure 90 days is not exceeded; and - Ensure enrollment and withdrawal forms are submitted correctly and on time to the PHR staff 3.5.09 Review submitted reports to ensure data quality. This includes: Suggested Activity - Quarterly, review 25% of enrolled sites to ensure contacts are listed correctly in Syntropi; and - Quarterly, review 25% of enrolled sites and provide education for the Vaccine borrowing and Vaccine transfer forms 3.5.10 Review monthly data logger reports for 25% of providers in LHD Suggested Grantee's jurisdiction to validate the accuracy of provider- Activity submitted monthly temperature reporting forms 3.5.11 Review monthly data logger reports to validate the accuracy of Standard provider-submitted monthly temperature reporting forms for all (Conditional) providers within LHD Grantee's jurisdiction who experience a vaccine loss as a result of temperature excursions 3.5.12 Conduct a monthly review of 10% of randomly selected providers Suggested in LHD Grantee's jurisdiction to identify vaccine loss report forms Activity that were completed in VAOS but were not submitted 3.5.13 Conduct a quarterly review of 25% of providers in LHD Grantee's Suggested jurisdiction to identify those that have adjusted more than 10% of Activity their vaccine inventory 3.5.14 Conduct a quarterly review of 25%of providers in LHD Grantee's Suggested jurisdiction to ensure the reported patient population matches the Activity number of doses ordered DSHS Contract No.HHS000109900001 Page 19 of 33 Amendment 4 DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 3.5.15 Utilize the CDC IQIP database and directly enter data to document Required IQIP follow-ups visits conducted at TVFC provider offices Activity 3.6. PROVIDER ACCOUNTABILITY 3.6.01 Track, report and follow up on vaccine fraud and abuse cases Standard (Universal) 3.6.02 Complete program evaluation activities with TVFC and ASN Required providers to address issues identified as noncompliance issues Activity For all TVFC providers, document corrective action plans in the CDC PEAR system as a contact 3.7. RE STAFF EDUCATION 3.7.01 Train LHD Grantee's staff to follow the policies and procedures Required Activity outlined in the TVFC &ASN Program Operations Manual for Responsible Entities. Provide training on TVFC and ASN requirements and updates (as described in the TVFC &ASN Program Operations Manual for Responsible Entities) annually at a minimum 3.7.02 For personnel identified by DSHS, attend and/or complete the Required Activity following trainings: - CDC Immunization Trainings; - TVFC/ASN Annual Trainings; - Annual Responsible Entity Training; and - Public Health Region(PHR) Trainings 3.7.03 Ensure that the TVFC &ASN Coordinator conducts quality Suggested Activity assurance on 10% of the temperature recording logs that were reviewed by their staff each quarter 3.8. RE COMPLIANCE 3.8.01 Comply with the current DSHS Immunization Contractor's Standard Guide for Local Health Departments and the TVFC and ASN (Universal) Operations Manual for Responsible Entities 3.8.02 Receive regional approval for any vaccine transfers and Standard document those transfers in VAOS within 24 hours of the (Universal) transfer occurring DSHS Contract No.HHS000109900001 Page 20 of 33 Amendment 4 DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 3.8.03 Address general inquiries by providers about the TVFC/ASN Standard Program, and ensure timely follow-up on requests for (Universal) information 3.8.04 Ensure that providers within LHD Grantee's jurisdiction are Required Activity adhering to the vaccine borrowing procedures outlined in the TVFC and ASN Provider Manual Report the number of borrowing forms submitted by quarter in the Immunization Inter-Local Agreement(ILA) Quarterly Report 3.9. RE EMERGENCY RESPONSE 3.9.01 Communicate the importance of an Emergency Vaccine Storage Standard (Universal) and Handling Plan to all clinics in the LHD Grantee's jurisdiction. Provide technical assistance to support the successful activation of each clinic's Emergency Vaccine Storage and Handling Plan 3.9.02 Transfer, accept, and store TVFC and ASN vaccines from Standard(Universal) clinics in the LHD Grantee's jurisdiction if there is a failure in the clinic's Emergency Vaccine Storage and Handling Plan 3.9.03 Be prepared to pack and ship vaccine to other sites, as directed Required Activity by the DSHS Immunization Unit 4. EPIDEMIOLOGY & SURVEILLANCE 4.1. PERINATAL HEPATITIS B CASE IDENTIFICATION 4.1.01 Conduct identification and case management of perinatal Standard(Universal) hepatitis B cases 4.1.02 Determine the number of newborns that do not receive the Required Activity first dose of the hepatitis B vaccine and/or HBIG and work with those facilities to ensure all at-risk infants receive the hepatitis B vaccine series and HBIG within 12 hours of birth 4.1.03 Ensure timely follow-up and reporting of case status of Required Activity possible moms as reported by DSHS within 2 weeks of receipt of report DSHS Contract No.HHS000109900001 Page 21 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 4.2. PERINATAL HEPATITIS B CASE MANAGEMENT 4.2.01 Contact and provide case management to 100% of hepatitis Required Activity B surface antigen-positive pregnant women identified, along with their infants and contacts 4.3. PERINATAL HEPATITIS B REPORTING 4.3.01 For all cases documented as 'lost-to-follow-up' on the Required Activity Perinatal Hepatitis B case management form, report the number and types of attempted activities performed in locating the mother or guardian of the infant to the DSHS Immunization Unit on the Perinatal Hepatitis B case management form 4.4. PERINATAL HEPATITIS B EDUCATION 4.4.01 Require Perinatal Hepatitis B Case Manager to attend the Required Activity biannual conference 4.4.02 Conduct educational training for hospitals, prenatal care Required Activity providers,pediatricians, birthing facilities, and other healthcare providers/facilities within the Grantee's jurisdiction, to increase identification, timely reporting, and appropriate case management of pregnant woman with hepatitis and their infants and contacts. 4.4.03 Work with partners, as appropriate, to ensure coordination Standard(Universal) of activities aimed at preventing perinatal hepatitis B transmission 4.5. DISEASE SURVEILLANCE 4.5.01 Complete investigation and document at least 90% of Required Activity confirmed or probable reportable vaccine-preventable disease (VPD) cases within thirty(30)days of initial report to public health 4.5.02 Adhere to the DSHS Emerging and Acute Infectious Standard(Universal) Disease Guidelines and current Epi Case Criteria Guide in conducting all activities DSHS Contract No.HHS000109900001 Page 22 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 4.5.03 Ensure all new VPD surveillance staff attend'Introduction Required Activity to NBS'training and complete the certification process in order to gain access to the NBS system 4.5.04 Complete all data entry into the Texas National Electronic Standard (Universal) Disease Surveillance System (NEDSS) Base System (NBS) following the NBS Data Entry Guidelines 4.5.05 Routinely review and follow up on all VPD laboratory Standard (Universal) reports received, including electronic lab reports (ELRs) generated through NBS in a timely fashion 4.5.06 Verify and enter complete vaccination history in NBS on Required Activity all VPD investigations with case status of confirmed or probable. Complete vaccination history can be assessed through the Texas Immunization Registry,provider offices, school records, and/or patient records 4.5.07 Initiate vaccine-based disease control activities by Standard (Universal) identifying population in need of a vaccination response and requesting vaccination services for that population by contacting the DSHS Vaccine-Preventable Disease (VPD) Surveillance Team Lead 4.6. DISEASE SURVEILLANCE EDUCATION 4.6.01 Educate physicians, laboratories, hospitals, schools, child- Suggested Activity care staff, and other health providers on VPD reporting requirements 4.7. NEEDS ASSESSMENT 4.7.01 Conduct a community needs assessment to identify gaps Required Activity in coverage rates or"pockets of need" for immunization activities. • Select an area of focus from the list of measurements provided in the Metrix or obtain approval from Immunization Unit epis for an alternate area of focus. • Create an assessment plan, collect data, gather stakeholder feedback, and analyze the information 4.7.02 Design an intervention to address the need identified in Suggested Activity 4.7.01 DSHS Contract No.HHS000109900001 Page 23 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 PROVIDING A VACCINE SAFETY NET 5.1. CLINIC ENROLLMENT 5.1.01 Enroll all eligible LHD clinics into the TVFC and ASN Required Programs as providers Activity 5.1.02 Provide immunization services according to national Standard standards for immunization practices for infants, children, (Universal) adolescents, adults, and healthcare workers. LHD clinics will comply with the National Childhood Vaccine Injury Act of 1986 5.2. CLINIC STAFF TRAINING 5.2.01 Train all clinic staff on the policies outlined in the TVFC Required and ASN Provider Manual and LHD procedures for Activity implementing them. These include: - procedures for following storage and handling guidelines; - procedures for vaccine management; and - procedures for using the DSHS vaccine management system (VAOS)procedures for other compliance guidelines 5.2.02 Develop clinic staff education requirements. Ensure that Required persons who administer vaccines and staff that are involved Activity in the vaccine administration process (including those who screen immunization records and administer vaccines)to follow Advisory Committee on Immunization Practices (ACIP) standards for children and adults and are knowledgeable on immunizations and immunization practices This can be accomplished by having staff complete the most current CDC Pink Book(Epidemiology and the Prevention of Vaccine Preventable Diseases)training and appropriate Vaccine Education Online (VEO) modules 5.2.03 Develop eligibility screening and documentation policy for Required all LHD clinics. Provide training to all staff on appropriate Activity screening and documentation for TVFC eligibility to ensure TVFC vaccine is administered only to TVFC-eligible children. Implement policy and plan for routine adherence to eligibility policies DSHS Contract No.HHS000109900001 Page 24 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 5.2.04 Develop and implement a policy on the use of the Texas Required Immunization Registry. Train LHD staff on conducting Activity client searches in the Texas Immunization Registry and how to effectively enter client demographic and immunization information 5.3. CLINIC IMMUNIZATION PRACTICES 5.3.01 Comply with current applicable state and federal standards, Standard policies and guidelines for clinics (Universal) 5.3.02 Provide vaccines regardless of residency or ability to pay Standard (Universal) 5.3.03 Adhere to clinical records retention schedule Standard (Universal) 5.3.04 Explain the benefits of a"medical home" and assist the Standard parent/guardian in obtaining or identifying the child's (Universal) medical home 5.3.05 Discuss the next ACIP-recommended vaccines and refer the Standard client to a medical home to complete the vaccination series (Universal) 5.3.06 Maintain a list of current providers within the LHD's Standard jurisdiction who accept children on Medicaid or CHIP and (Universal) make this list available to clinic clients and families as needed 5.3.07 Refer uninsured clients to Medicaid or the Children's Health Standard Insurance Program (CHIP) as appropriate (Universal) 5.3.08 Ensure that all ACIP-recommended vaccines are routinely Standard available and offered to TVFC patients (Universal) 5.3.09 Ensure that all vaccines listed on the ASN vaccine formulary Standard are available and offered to eligible adult patients (Universal) 5.3.10 Establish"standing orders" for vaccination in LHD Grantee's Required clinics that are consistent with legal requirements for standing Activity orders (including, but not limited to, those found in the Texas Medical Practice Act) 5.3.11 Search for the client's immunization history at every client Standard encounter. Compare all immunization histories (Texas (Universal) Immunization Registry, TWICES or EMR system, validated patient-held records, clinic medical record) and enter into the Texas Immunization Registry all historical immunizations not in the Registry at every client encounter. Review the client's record for vaccines due and overdue according to the CDC recommended schedules at: https://www.cdc.gov/vaccines/schedules/index.html DSHS Contract No.HHS000109900001 Page 25 of 33 Amendment 4 DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 5.3.12 Offer updated Immunization History Report to the client or Standard client's parent or guardian at every client encounter (Universal) 5.3.13 Follow and explain recommended guidelines for obtaining Standard and submitting ImmTrac2 consent forms according to the (Universal) instructions found at http://www.dshs.texas.gov/immunize/immtrac/forms.shtm 5.3.14 Report to the Texas Immunization Registry all immunizations Standard administered to consented children(younger than 18 years of (Universal) age) and consented adults in LHD Grantee's clinics, either by entering data directly into the Registry or through electronic data exchange via TWICES or an electronic medical record (EMR) system 5.3.15 Verbally and with DSHS-produced literature, inform parents Standard at LHD Grantee's clinics about the Texas Immunization (Universal) Registry, the benefits of inclusion in the Registry, and the importance of maintaining a complete immunization history in the Registry 5.3.16 Update all demographic information, including address, Standard email, and telephone number, at every client encounter in (Universal) EMR and the Texas Immunization Registry 5.3.17 Verbally educate patients and parents/guardians about the Standard benefits and risks of vaccination and distribute DSHS (Universal) educational materials, as applicable, as part of this conversation 5.3.18 Follow only medically supportable contraindications to Standard vaccination (Universal) 5.3.19 Provide immunization services at times other than 8 am to 5 Required pm, Monday through Friday, at least once per month Activity 5.3.20 Institute infection control practices, including effective hand Standard washing and management of hazardous waste (Universal) 5.3.21 Maintain confidentiality of client information Standard (Universal) 5.3.22 Recommend the simultaneous administration of all needed Standard vaccines for the patient (Universal) 5.3.23 Implement clinic policy on screening and documentation of Standard eligibility for TVFC vaccines. The policy must be consistent (Universal) with the TVFC requirements outlined in the current TVFC and ASN Provider Manual 5.3.24 Participate in public health emergencies and exercises that Suggested may require vaccine administration to the public or first Activity responders DSHS Contract No.HHS00010990000I Page 26 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 5.3.25 Conduct outreach activities to raise the immunization Suggested coverage levels of uninsured adults by visiting sites such as Activity homeless shelters,halfway houses, day labor sites or other locations 5.3.26 Coordinate with community vaccinators to conduct annual Suggested employee-based vaccination clinics for influenza vaccine Activity administration 5.4. CLINIC VACCINE MANAGEMENT 5.4.01 Ensure that all expired and spoiled/wasted vaccines are Required Activity appropriately identified and entered into the Vaccine Allocation and Ordering System (VAOS) for the LHD Grantee's clinics 5.4.02 Submit returns for all vaccines distributed via CDC's Standard centralized distributor back to the centralized distributor for (Universal) returns processing 5.5. CLINIC QUALITY ASSURANCE 5.5.01 Ensure that appropriate routine and emergency vaccine Required Activity storage and handling plans are in place at each of the LHD Grantee clinic locations 5.5.02 Ensure that expired, wasted, and unaccounted-for vaccines Standard (excluding flu)do not exceed 5 percent in LHD Grantee's (Universal) clinics 5.6. CLINIC REPORTING 5.6.01 Conduct timely reporting of monthly clinic activities by Required Activity recording vaccine inventory, doses administered, temperature logs and other reportable activities by the 5th of each month as described in the TVFC/ASN Provider Manual 5.6.02 Report all notifiable conditions as specified in the DSHS Standard(Universal) Immunization Contractor's Guide for Local Health Departments 5.6.03 Report all vaccine adverse events as specified in the DSHS Standard(Universal) Immunization Contractor's Guide for Local Health Departments DSHS Contract No.HHS000109900001 Page 27 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 5.6.04 Report the number of unduplicated underinsured clients Required Activity and the number of doses administered to underinsured children monthly as specified in the DSHS Immunization Contractor's Guide for Local Health Departments 5.6.05 Conduct monthly reporting of doses administered to Required Activity women veterans, as required in the ASN Program INCREASING USE OF THE TEXAS IMMUNIZATION REGISTRY 6.1. TEXAS IMMUNIZATION REGISTRY OUTREACH FOR IMMUNIZATION RECORDS 6.1.01 Conduct Texas Immunization Registry outreach to Suggested organizations regarding missing vaccinations for children and Activity adults for whom consent has been granted but who do not have complete immunization records 6.2. TEXAS IMMUNIZATION REGISTRY OUTREACH FOR PATIENT CONSENTS 6.2.01 Conduct activities aimed at increasing the consent rate for all Suggested age groups, including adults and individuals identified as Activity recently moved in-state 6.2.02 Conduct at least twelve (12) outreach and educational Required Activity activities focused on 18-year-olds in high schools and colleges/universities in LHD Grantee's jurisdiction 6.3. TEXAS IMMUNIZATION REGISTRY OUTREACH TO USERS 6.3.01 Conduct outreach to existing Registry users who have not Required Activity logged into the Registry in the last 90 days 6.3.02 Provide orientation to all new Texas Immunization Registry Suggested organizations within the LHD Grantee's jurisdiction at least Activity once a year and maintain documentation of all technical assistance provided (e.g., telephone logs) Provide education and training on the effective use of the Texas Immunization Registry according to the Guidelines for Increasing the Use of the Texas Immunization Registry Identify and assist newly registered providers and new users reporting to the Texas Immunization Registry DSHS Contract No.HHS000109900001 Page 28 of 33 Amendment 4 DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 6.4. TEXAS IMMUNIZATION REGISTRY USER EDUCATION 6.4.01 Provide education, training, and technical assistance to Suggested Activity promote the effective use of the Texas Immunization Registry by organizations 6.4.02 Identify and assist providers to establish electronic Required Activity affirmation of consent 6.5. TEXAS IMMUNIZATION REGISTRY PROMOTION 6.5.01 Promote the use of the Texas Immunization Registry to Required organizations within the LHD Grantee's jurisdiction that are Activity not currently enrolled in the Registry. Identify all providers who administer vaccine in awardee's jurisdiction, including both pediatric and adult immunization providers. Educate them on their statutory requirement to report immunizations and on the enrollment process 6.5.02 Provide education and technical assistance to birth registrars on Suggested the effective use of the Texas Immunization Registry Activity 6.5.03 Collaborate with prenatal healthcare providers,birth registrars, Suggested hospital staff,pediatricians, and other entities to educate Activity parents, expectant parents, and providers about the Texas Immunization Registry and the benefits of participation. This includes the dissemination of DSHS educational materials as appropriate 6.6. TEXAS IMMUNIZATION REGISTRY PROGRAM QUALITY IMPROVEMENT 6.6.01 Review the monthly Provider Activity Report(PAR)to Required Activity identify organizations who are inactive or not routinely submitting immunization data or adding consented clients. Prioritize these organizations for outreach activities 6.6.02 Review the quarterly Consent Accepted Rate Evaluation Required Activity (CARE)report to target organizations with largest client volume and/or lowest consent acceptance rate. Prioritize these organizations for outreach activities DSHS Contract No.HHS000109900001 Page 29 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 6.6.03 Conduct a minimum of 60 Texas Immunization Registry Required Activity organization quality improvement assessments per FTE each year as described in the Guidelines for Increasing the Use of the Texas Immunization Registry. (For jurisdictions with less than 60 orgs, conduct quality improvement assessment visits to 100% of your orgs) L EDUCATION AND PARTNERSHIPS 7.1 PUBLIC EDUCATION 7.1.01 Inform and educate the public about vaccines and vaccine- Required preventable diseases Activity 7.1.02 Inform the general public about the TVFC and ASN Programs Required and the eligibility criteria for qualifying for the programs Activity 7.2 PROVIDER EDUCATION 7.2.01 Educate and update providers on the most current ACIP Suggested recommendations for all age groups Activity 7.2.02 Inform and highly recommend to the medical community and Suggested local providers within the LHD Grantee's jurisdiction the most Activity current Centers for Disease Control and Prevention(CDC) Epidemiology and Prevention of Vaccine-Preventable Disease (EPI-VAC) training(https://www.cdc.gov/vaccines/ed/webinar- epv/index.html). The most current"Pink Book,"titled Epidemiology and Prevention of Vaccine-Preventable Diseases, can be found on the CDC website at http://www.cdc.gov/vaccines/pubs/pinkbooldindex.html 7.2.03 Provide information to community healthcare employers Suggested (hospitals, clinics, doctor offices, long-term care facilities) about Activity the importance of vaccination of healthcare workers 7.2.04 Provide training relating to Standards for Child and Adolescent Suggested Immunization Practices and Standards for Adult Immunization Activity Practices to all immunization providers within LHD Grantee's jurisdiction DSHS Contract No.HHS000109900001 Page 30 of 33 Amendment 4 DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 7.2.05 Provide training opportunities and/or resources to assist Required immunization providers in communicating with patients and/or Activity parents (e.g., making a strong recommendation, addressing vaccine hesitancy, etc.) 7.3 STAFF EDUCATION 7.3.01 Work to ensure that all Immunization Program Grantee staff are Standard knowledgeable about vaccines and VPDs (Universal) 7.3.02 Develop and implement a written communications and Required Activity customer service plan for Grantee's staff to ensure customers receive consistent, correct immunization information and services in a courteous and friendly manner on a timely basis 7.3.03 Educate healthcare workers on the importance of keeping Required Activity themselves up-to-date with the vaccine schedule 7.4 COALITION BUILDING 7.4.01 Appoint an immunization coalition coordinator Required Activity 7.4.02 Attend and participate in required coalition trainings sponsored Required Activity by DSHS 7.4.03 Develop and maintain a planning group with the goal of Suggested Activity sustaining a coalition 7.4.04 Engage and recruit community groups and immunization Suggested Activity stakeholders into a coalition 7.4.05 Facilitate and host coalition meetings Suggested Activity 7.4.06 Participate in monthly calls to provide updates on coalition Required Activity collaboration activities 7.4.07 Provide signed letters of agreement and other documentation of Suggested Activity commitment to participate in coalition 7.4.08 Document communications, group meetings, and planning of Required Activity activities that promote the best practices identified in contract agreement(documents are to be accessible during site visits) 7.5 COMMUNITY PARTNERSHIP DSHS Contract No.HHS000109900001 Page 31 of 33 Amendment 4 DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 7.5.01 Plan and implement community education activities and Required Activity partnerships aimed at improving and sustaining immunization coverage levels 7.5.02 Conduct outreach and collaborative activities with American Required Activity Indian tribes, if applicable 7.5.03 Participate in at least one collaborative meeting concerning Required Activity tribal health issues, concerns, or needs with American Indian tribal members, if applicable 7.5.04 Coordinate educational and other activities with local Women, Suggested Activity Infants, and Children(WIC)programs to ensure that children participating in WIC are screened and referred to their"medical home"for vaccination using a documented immunization history in accordance with the Standards for Child and Adolescent Immunization Practices 7.5.05 Offer educational opportunities to all WIC Programs in the Suggested Activity service area, including information about online and satellite- broadcast continuing education opportunities from the CDC Continuing Education website at https://www.cdc.gov/vaccines/ed/index.html 7.5.06 Engage in education and partnerships aimed at reducing or Required Activity eliminating coverage disparities by race, ethnicity, and socioeconomic status 7.5.07 Maintain a contact list of providers, hospitals, schools, child- Required Activity care facilities, social service agencies, and community groups involved in promoting immunizations and reducing vaccine- preventable diseases 7.5.08 Participate in special initiatives as directed by the DSHS Required Activity Immunization Unit 7.5.09 Implement the DSHS Immunization Ambassador Program Required Activity throughout Grantee's jurisdiction 7.6 STAKEHOLDER ENGAGEMENT 7.6.01 Attend all Texas Immunizers and Stakeholders Working Required Activity Groups (TISWG)and other designated stakeholder meetings (these meetings can be attended remotely) 7.6.02 Host at least 1 immunization stakeholder meeting per Suggested Activity quarter(4 per contract year) DSHS Contract No.HHS000109900001 Page 32 of 33 Amendment 4 DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1 7.7 MEDIA CAMPAIGNS 7.7.01 Distribute ASN information and educational materials at Required Activity venues and clinics that serve eligible adults 7.7.02 Distribute TVFC information and educational materials at Required Activity venues that parents of TVFC-eligible children might frequent 7.7.03 Participate,when directed, in statewide media campaigns by Required Activity distributing DSHS-developed and produced public service announcements and materials to local television and radio stations, newspapers,parent publications, university newspapers, high school newspapers, and neighborhood newspapers 7.7.04 Promote www.ImmunizeTexas.com,the Immunization Unit's Required Activity website; and any other Immunization Unit newsletters to providers in the LHD Grantee's jurisdiction 7.7.05 Use national immunization observances as opportunities to Required Activity conduct specific education and promotional activities to give emphasis to the importance and benefits of vaccines: National Infant Immunization Week(NIIW),National Immunization Awareness Month(NIAM), and National Influenza Immunization Week(NIIW) 7.7.06 Share available federal, state, and/or local adolescent Required Activity vaccination coverage and/or vaccine-uptake-related data with partner organizations, adolescent immunization providers, and other stakeholders DSHS Contract No.HHS000109900001 Page 33 of 33 Amendment 4 DocuSign Certificate Of Completion Envelope Id:B2CCD95CF3AB4BF896184AC2AA9A5FD1 Status: Sent Subject:Please DocuSign:HHS000109900001 -City of Port Arthur-FY23 IMM LOCALS-A-4 Source Envelope: Document Pages:33 Signatures: 1 Envelope Originator: Certificate Pages:5 Initials:0 CMS Internal Routing Mailbox AutoNav:Enabled 11493 Sunset Hills Road Envelopeld Stamping:Enabled #100 Time Zone:(UTC-06:00)Central Time(US&Canada) Reston,VA 20190 CMS.InternalRouting@dshs.texas.gov IP Address: 167.137.1.16 Record Tracking Status: Original Holder:CMS Internal Routing Mailbox Location:DocuSign 4/22/2022 8:58:37 AM CMS.InternalRouting@dshs.texas.gov Signer Events Signature Timestamp Judith Smith '—DotulS' tr y: Sent:4/22/2022 9:05:41 AM / judith.smith@portarthurtx.gov Sol& Viewed:4/22/2022 9:20:18 AM `—F046504AE030471... Director of Health Services Signed:4/22/2022 9:27:52 AM City of Port Arthur Security Level:Email,Account Authentication Signature Adoption:Pre-selected Style (None) Signed by link sent to judith.smith@portarthurtx.gov Using IP Address: 71.40.211.219 Electronic Record and Signature Disclosure: Accepted:4/22/2022 9:20:18 AM ID:9a15f480-daa4-4c74-b3ff-5400ec31e878 Ron Burton,City Manager Sent:4/22/2022 9:27:56 AM ron.burton@portarthurtx.gov City Manager City of Port Arthur Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Accepted:4/20/2022 2:42:18 PM ID:ae83aa89-6f00-4aad-acc6-6a3f917b8e6c Susana Garcia Susana.Garcia@dshs.texas.gov Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Accepted:4/22/2022 8:18:37 AM ID:fe6a12c5-5f02-48fd-94ec-b3a8fd3848df Patty Melchior Patty.Melchior@dshs.texas.gov Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Accepted:4/22/2022 8:43:50 AM ID: 1e63b14c-6ef3-4071-ab11-9fc7e72060ab Imelda Garcia imeldam.garcia@dshs.texas.gov Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Signer Events Signature Timestamp Accepted:7/6/2021 8:08:45 AM ID: 1a6909aa-b026-45a9-be9f-4240c2e32ff9 In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp CMS Internal Routing cms.internalrouting@dshs.texas.gov Security Level: Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Beatrice Avalos beatrice.avalos@dshs.texas.gov Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 4/22/2022 9:05:42 AM Payment Events Status Timestamps Electronic Record and Signature Disclosure Electronic Record and Signature Disclosure created on:9/14/2020 7:10:18 PM Parties agreed to:Judith Smith,Ron Burton,City Manager,Susana Garcia,Patty Melchior,Imelda Garcia ELECTRONIC RECORD AND SIGNATURE DISCLOSURE From time to time, DSHS Contract Management Section (we, us or Company) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the DocuSign system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to this Electronic Record and Signature Disclosure(ERSD),please confirm your agreement by selecting the check-box next to `I agree to use electronic records and signatures' before clicking `CONTINUE' within the DocuSign system. Getting paper copies At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you through the DocuSign system during and immediately after the signing session and, if you elect to create a DocuSign account, you may access the documents for a limited period of time (usually 30 days) after such documents are first sent to you. After such time, if you wish for us to send you paper copies of any such documents from our office to you, you will be charged a $0.00 per-page fee. You may request delivery of such paper copies from us by following the procedure described below. Withdrawing your consent If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below. Consequences of changing your mind If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to receive required notices and consents electronically from us or to sign electronically documents from us. All notices and disclosures will be sent to you electronically Unless you tell us otherwise in accordance with the procedures described herein,we will provide electronically to you through the DocuSign system all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us. How to contact DSHS Contract Management Section: You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows: To contact us by email send messages to: alison.joffrion@hhsc.state.tx.us To advise DSHS Contract Management Section of your new email address To let us know of a change in your email address where we should send notices and disclosures electronically to you, you must send an email message to us at alison.joffrion@hhsc.state.tx.us and in the body of such request you must state: your previous email address, your new email address. We do not require any other information from you to change your email address. If you created a DocuSign account, you may update it with your new email address through your account preferences. To request paper copies from DSHS Contract Management Section To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must send us an email to alison.joffrion@hhsc.state.tx.us and in the body of such request you must state your email address, full name, mailing address, and telephone number. We will bill you for any fees at that time, if any. To withdraw your consent with DSHS Contract Management Section To inform us that you no longer wish to receive future notices and disclosures in electronic format you may: i. decline to sign a document from within your signing session, and on the subsequent page, select the check-box indicating you wish to withdraw your consent, or you may; ii. send us an email to alison.joffrion@hhsc.state.tx.us and in the body of such request you must state your email, full name, mailing address, and telephone number. We do not need any other information from you to withdraw consent.. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process.. Required hardware and software The minimum system requirements for using the DocuSign system may change over time. The current system requirements are found here: https://support.docusign.com/guides/signer-guide- signing-system-requirements. Acknowledging your access and consent to receive and sign documents electronically To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please confirm that you have read this ERSD, and(i)that you are able to print on paper or electronically save this ERSD for your future reference and access; or(ii) that you are able to email this ERSD to an email address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format as described herein, then select the check-box next to `I agree to use electronic records and signatures' before clicking `CONTINUE' within the DocuSign system. By selecting the check-box next to `I agree to use electronic records and signatures', you confirm that: • You can access and read this Electronic Record and Signature Disclosure; and • You can print on paper this Electronic Record and Signature Disclosure, or save or send this Electronic Record and Disclosure to a location where you can print it, for future reference and access; and • Until or unless you notify DSHS Contract Management Section as described above, you consent to receive exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you by DSHS Contract Management Section during the course of your relationship with DSHS Contract Management Section.